2016_070816 IRRIGATION � DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � j;► ��3`T��/��J
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
��IReduced Pressure Principle '� �Reduced Pressure Principle-Detector
�ouble Check Valve i �Double Check-Detector
� PressureVacuumBreaker I Spill-Resistant Pressure Vacuum Breaker
Manufacturer �
/a��i� �ry �Model Number —3 �C� Size_ ��
r
Located At ��[^�✓v l �/�¢�,d Serial Number� S�� � 7,�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�• `r psid Held at �•�psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
Leakedl '� Leaked I Did not open 1� 1 Did not open I ' Leaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight'.1 ClosedTightl � psid psid psid
Test gauge used: Make/ModelGd�!/.S,/1/�tr� LiG--2a'r! � f'1�/ SN���-/ 1(� g 7
Date Tested for Accuracy: �' ��.��
Remarks:
The above is certified to be true at the time of testing.
Firm Names',� ��� Firm Address�(i�7�,L�AS?YiL�-�/ ���5� J�
Certified Tester(print�rC��L�v'`Z��iG Certified Tester(signature�����f�.�['�.�����'�
Firm Phone#��,�'������Cert.Tester No. �,S/� Date �
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow- Customer Copy Pink-Tester's Copy